Differential diagnosis for plaque

psoriasis
Plaque pattern for psoriasis
Well-defined
Pink or red with large, centrally adherent, silvery-
white, polygonal scale
Symmetrical site on the elbow, knee, lower back
and scalp

Differential diagnosis for plaque
psoriasis
Discoid eczema
a chronic eczema that produces coin-shaped spots on
the skin.
Absence of a sharp margin
May be exudative or crusted, lack thick scale




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Psoriasis
Discoid eczema
Differential diagnosis for plaque
psoriasis
Seborrhoeic eczema

chronic, relapsing inflammatory condition of the skin
that presents with scaling and poorly defined
erythematous patches

Absence of a sharp margin

itchy, red, scaly skin






.

Differential diagnosis for plaque
psoriasis
Tinea
any fungus parasitic on the skin

Presentation depends upon the site and types of fungus

Solitary or few lesion, asymmetrical, expanding
Investigation
A diagnosis of psoriasis is usually based on the appearance of the
skin

There are no special blood tests or diagnostic procedures needed to
make the diagnosis

Throat swabbing
Beta-haemolytic streptococci in guttate psoriasis

Skin scrapings and nail clipping
Exclude tinea

Radiology and rheumatoid factor
Assess arthritis
Biopsy If the clinical diagnosis is uncertain
Regular elongation of rete ridges
Acanthosis - diffuse epidermal hyperplasia (thickening of the skin).
Parakeratosis (nuclei retained in the horny layer).
Dilated Blood Vessels in the elongated dermal papillae













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Triggering factors Aggravating factors
Physical trauma (Kebner phenomenon) -
Infection (especially streptococcal
pharyngitis)
-
Drugs : Lithium, beta blocker, antimalarial, ACEI, NSAID, Withdrawal of systemic
corticosteroid, Interferon
- Sunlight (in about 6%)
Psychological stress, anxiety & depression
Cigarettes and alcohol
Relevant history and physical finding
1. Age
Bimodal distribution of the age of onset

2. Onset
Sudden onset of many small areas of scaly redness
Worsening of a long-term erythematous scaly area

3. Family history of similar skin condition
Based on twin studies, the heritability of psoriasis has been
estimated to be 60%90%
HLA associations:
Cw6 (strongest) associated with early onset
B13, DR7, B17, B57 associated with earlier onset
B27 associated with psoriatic arthritis


4. Site
Palms and soles (palmoplantar psoriasis)
Intertriginous areas (inverse psoriasis )
Generalized erythema and scaling (Erythrodermic psoriasis)

5. Drug history
Lithium, beta blocker, antimalarial, ACEI, NSAID, withdrawal of
systemic corticosteroid, Interferon

6. Past medical history
Physical trauma (Kebner phenomenon)
Infection (especially streptococcal pharyngitis)
Psoriatic Arthritis (30%)
Crohns disease
hypertension, dysplipidemia, diabetes mellitus, cardiovascular
disease



Type of Arthritis % Features
Asymmetric
oligoarthritis
70% Single or multiple distal joints in hands or feet involved;
synovitis and joint swelling(knees, ankles), swelling of digit
(sausage finger)
Asymmetrical
DIP arthritis
5
10%
Single or multiple DIP joint involvement; periarticular
swelling with concomitant nail involvement
Symmetrical
polyarthritis
(RA-like)
15% Involvement of small and medium-sized joints (PIP, MCP,
wrists, elbows)
Spondylitis and
sacroiliitis
5% Typically in men and resembles ankylosing spondylitis, with
addition of knee and sacroiliac involvement
Arthritis mutilans 5% Digits become shorter, wider, softer due to osteolysis of
phalanges and metacarpals; results in telescoping motion of
digits
Initial lesions are
usually
erythematous
macules or maculo-
papules, which can
be as small as 2 mm
in diameter.
By peripheral
extension large,
scale covered
patches appear.
When the patches
persist for a long
time, the skin
becomes thickened,
develop fissures and
thick scales cover
the lesion
Signs of psoriasis
If the scales are scratched away from the lesion, they
fall of as tiny flakes (Candle sign)
If the scale is removed totally, a moist, thin,
translucent layer of skin is revealed. The lesion
remains dry until this last level is reached (sign of the
last Hutchen)
If scratching is continued bleeding points appear
(Auspitz sign). These bleeding points are thought to
be the tips of the dermal papillae.

Psoriatic nails: may be sole involvement or part of
extensive disease
i. Pitting
ii. Subungual hyperkeratosis
iii. Oil spots
iv. Onycholysis
v. Splinter hemorrhages

Oral involvement

psoriasis may also affect the lid, conjunctiva
and give rise to ocular manifestations,
including ectropion and trichiasis,
conjunctivitis and conjunctival hyperemia
Blepharitis

Melanoma in situ. (The tumor remains in the epidermis, the
outermost layer of skin.)



Stage 5 years survival rate (%) 10 years survival rate (%)
Stage IA 97 95
Stage IB 92 86
Stage IIA 81 67
Stage IIB 70 57
Stage IIC 53 40
Stage IIIA 78 68
Stage IIIB 59 43
Stage IIIC 40 24
Stage IV 15 20 10 - 15
Melanoma
Aggressive tumor resulting from melanocytes and affecting
younger population (peak age 2045 years old)
Risk factors: tendency to sunburn/freckle, light-colored
skin/hair/eyes, immunosuppression (transplant patients with
threefold to fourfold higher risk )
Superficial spreading melanoma
characterized by a superficial radial growth
phase that occurs before an invasive vertical
growth phase
most common (70%)


presents as darkly pigmented macule or thin
plaque, notched border, varying shades of
brown, possible areas of regression
common site is back (men) and lower legs
(women)
Nodular melanoma
second most common type in light-skinned
patients
darkly pigmented papule or nodule with rapid
onset; vertical growth
Lentigo maligna melanoma
least common
evolves from lentigo
maligna, often in sun-
exposed sites in older age
group (head and neck)
Presents as
hyperpigmented patch
with varying shades of
brown, irregular border
Acral lentiginous melanoma
most common type
seen in darker-
skinned patients
occurs on the palms
and soles
often presents as
hyperpigmented
patch with varying
shades of brown or
black and irregular
borders
ABCDE rule for features of melanoma
A: Asymmetry
B: Border is irregular, notched, or blurred
C: Color is variable or irregularly distributed
D: Diameter is greater than 6 mm
E: Evolving or changing lesion
Other Presentations of Melanoma
Melanoma in situ (MIS) - proliferation of
malignant melanocytes confined to the
epidermis
Vulvovaginal melanoma
Subungual melanoma
Primary ocular melanoma
Familial melanoma - mutation in the CDKN2A
suppressor gene
Liver diseases
Spider angiomas
Palmar erythema
Gynecomastia
Terrys nails
Jaundice
Pruritis

Pyoderma Gangrenosum
painful ulcers with boggy, undermined edges and a border of
gray or purple pigmentation.
The ulcers often follow trauma and begin as pustules or
nodules that ulcerate and extend centrifugally.

legs are the most common site for the ulcers.
50% of patients have underlying rheumatoid arthritis or
inflammatory bowel disease.
multiple myeloma
leukaemia

Acrodermatitis Enteropathica (ACE)
Is an inherited or acquired condition due to zinc deficiency.
Acral and periorificial: pustules, bullae and scaling.
Most patients have diarrhea.
Treatment is zinc supplementation.

Necrolytic Migratory Erythema
(glucagonoma syndrome)
is rare, characterized by erythematous, scaly plaques
on Acral, Periorificial or Intertriginous areas +
hyperglycemia, diarrhea, weight loss, and atrophic glossitis.
Is in association with an islet cell tumor of the pancreas.
Treatment is removal of the tumor.


Peutz-Jeghers Syndrome
lentigines (Lentigo: a brown pigmented spot ) on the skin
(periorbital region, dorsal surfaces of the fingers and toes)
and mucosa (lips, buccal mucosa)
Associated with hamartomas (polyps) of the stomach, small
intestine, and colon
The polyps may cause intussusception and rarely undergo
malignant change


Lichen planus
violaceous, flat, polygonal papules on the flexor aspects of the
wrists, trunk, medial thighs, genitalia, and oral mucosa.
May occur with:
- Primary biliary cirrhosis
- Hepatitis B virus immunization or
- Gold therapy
- In hepatitis C patients:
Oral erosive lichen planus.
Dermatitis Herpetiformis (DH)
is a chronic, intensely pruritic blistering disease
Most patients have an asymptomatic gluten-
sensitive enteropathy
less commonly thyroid disease.
Sweet syndrome gastro?
Erythema nodusum
Aphthous stomatitis

Porphyria cutanea tarda (hep b)
Helicobacter sweets syndrome
Sister mary josephs nodules
Amyloidosis
may be a sign of multiple myeloma
nonpruritic, nontender, shiny, waxy papules,
which commonly develop on the eyelids, also
know as raccoon eyes
can also be present in the skin folds, the
retroauricular folds, the anogenital region, or
the oral mucosa.
Many have macroglossia
amyloid deposition is also responsible for
peripheral neuropathy, carpal tunnel
syndrome, orthostatic hypotension
(autonomic neuropathy), congestive heart
failure, and nephrotic syndrome.


Sweet syndrome
(acute febrile neutrophilic dermatosis)
A spectrum of diseases based on
histopathological finding of neutrophilic inflitrate
without evidence of infectious agent
Tender, erythematous edematous papules and
plaques typically over face or upper extremities;
fever, malaise, leukocytosis; vesicobullous variant
frequently associated with myelogenous
leukemia
Malignancy: breast, GI tract
Benign association
URIs, Strep, RA, Crohns, sarcoidosis


Diagnostic criteria for classic Sweets or
MASS
Major criteria (both required)
1. Abrupt onset of painful erythematous plaques or nodules
2. Dense neutrophilic infiltrate

Minor criteria (two of four required)
1. Fever > 38
o
C
2. History of associated illness or malignancy
3. Response to treatment with potassium iodide or steroids
4. Three of four lab abnormalities:
- WBC > 8000
- Neutrophils > 70%
- ESR > 20
- Positive CRP
Cohen PR and Kurzrock R, Clin Dermatol (2000) 18, 265-282
Su WP and Liu HN, Cutis (1986) 37, 167-174
Anemia
Iron deficiency anemia: koilonychia, angular
stomatitis
Pernicious anemia: late onset vitiligo
Fanconi anemia (rare inherited bone marrow
failure syndromes): caf au lait spots, diffuse
hyperpigmentation (iron overload),
hypopigmented macules


Plasmacytoma
Malignant plasma cell tumor growing within
soft tissue or within the axial skeleton
nontender, smooth, cutaneous or
subcutaneous nodules 1-5 cm in diameter
flesh- or plum-colored, mostly distributed on
the extremities, trunk, and face.
cutaneous plasmacytosis
Conditions in Patients With
CD4+ Cell Counts Below 200/L
Photodermatitis
Psoriasis
Prurigo nodularis
Molluscum
drug reactions.
Diseases That Do Not Go Away
Even With Antiretroviral Therapy
Eczema and xerosis
Human papilloma virus-associated warts
Kaposis sarcoma

Conditions Emerging With Immune
Reconstitution Under Antiretroviral
Therapy
Acne
Staphylococcal infection
Erythema nodosum
HIV and HCV Coinfection
7- purpura:
1. Petechiae: are superficial, pinpoint (<3 mm), red or purple,
nonblanching macules that mostly occur in dependent areas.
Petechiae imply a platelet-related condition or vessel disease

2. Ecchymoses are larger than 3 mm, flat, and observed with
notable extravasation commonly known as a bruise.
Ecchymoses initially form an irregular purple patch, which
eventually turns yellow and fades.

underlying reasons for purpura can be
divided into several groups, as follows:
1. Thrombocytopenia (most common cause
for purpura) and platelet dysfunction
2. Vascular disorders (senile purpura,
Vasculitis - Henoch-Schnlein purpura)
3. Coagulation disorder:
1. Disseminated intravascular coagulation (DIC)
4. Infection - Meningococcemia




Conditions in Patients With
CD4+ Cell Counts Below 200/L

Hiv